Fibrinolytic treatment of intraventricular haemorrhage preceding surgical repair of ruptured aneurysms and arteriovenous malformations

Intraventricular haemorrhage due to re-ruptured arteriovenous malformation cleared with tissue plasminogen activator administered through a pre-existing ventriculoperitoneal shunt

In the context in intraventricular haemorrhage (IVH), intrathecal thrombolytic agents administered in conjunction with extraventricular drainage have been demonstrated to clear larger volumes of blood and reduce mortality rates. However, patients with arteriovenous malformations (AVM) have been mostly excluded from clinical trials. We describe a patient with hydrocephalus secondary to a ruptured AVM who was treated via external ventriculostomy, which was subsequently converted to a ventriculoperitoneal shunt (VPS). Eight months later, the AVM re-ruptured, causing IVH and rendering the patient comatose. Taking into consideration the patient's poor outlook, a single dose of intraventricular tissue plasminogen activator (t-PA) was administered through the shunt reservoir. The shunt maintained its function and the patient's condition ultimately improved. This impressive case demonstrates the utility of t-PA administered through an existing VPS in the setting of IVH due to ruptured AVM, highlighting its lifesaving potential in the appropriate patient and overall decrease in the cost of care by mitigating the need for shunt revision.

Intraventricular hemorrhage related to AVM rupture: Description, outcomes and impact of intraventricular fibrinolysis

OBJECTIVES

Arteriovenous malformation (AVM) rupture could lead to intraventricular hemorrhage (IVH), a particularly severe form of intracranial bleeding. The epidemiology, presentation, management and outcomes of IVH related to AVM rupture have not been clearly addressed yet. The aim of the present study was to investigate the characteristics of IVH related to AVM rupture, with particular attention paid to functional outcomes and to the impact of intraventricular fibrinolysis (IVF).

PATIENTS AND METHODS

Between 2011 and 2015, all patients suffering from IVH admitted in two tertiary neurosurgical centers were included in a prospective register. Patient with IVH related to AVM rupture were identified (n=29) and their data retrospectively collected. Particular attention was paid on patients who received IVF. We also compared them to 29 apparied aneurysmal IVH.

RESULTS

IVH related to AVM rupture often occurred in young patients. In most cases, intracerebral hemorrhage was associated to IVH. 17% of the patients died, and functional outcome at 6 months was similar to those with aneurysmal IVH. Interestingly, 5 patients received IVF and none experienced any rebleeding.

CONCLUSION

IVH related to AVM rupture is a severe form of hemorrhagic stroke, with a poor neurologic prognosis. IVF seems to be safe and may be considered in this particular form of IVH.

Pharmacokinetics and Pharmacodynamics of Tissue Plasminogen Activator Administered Through an External Ventricular Drain

BACKGROUND

Intraventricular hemorrhage (IVH) frequently complicates spontaneous intracerebral or subarachnoid hemorrhage (SAH). Administration of intraventricular tissue plasminogen activator (TPA) accelerates blood clearance, but optimal dosing has not been clarified. Using a standardized TPA dose, we assessed peak cerebrospinal fluid (CSF) TPA concentrations, the rate at which TPA clears, and the relationship between TPA concentration and biological activity.

METHODS

Twelve patients with aneurysmal SAH and IVH, treated with endovascular coiling and ventricular drainage, were randomized to receive either 2 mg intraventricular TPA or placebo every 12 h (five doses). CT scans were performed 12, 48, and 72 h after initial administration, and blood was quantified using the SAH Sum and IVH Scores. CSF TPA and fibrin degradation product (D-dimer) concentrations were measured at baseline and 1, 6, and 12 h after the first dose using ELISA assays.

RESULTS

Median CSF TPA concentrations in seven TPA-treated patients were 525 (IQR 352-2129), 323 (233-413), and 47 (29-283) ng/ml, respectively, at 1, 6, and 12 h after drug administration. Peak concentrations varied markedly (401-8398 ng/ml). Two patients still had slightly elevated levels (283-285 ng/ml) when the second dose was due after 12 h. There was no significant correlation between the magnitude of CSF TPA elevation and the rate of blood clearance or degree of D-dimer elevation. D-dimer peaked at 6 h, had declined by 12 h, and correlated strongly with radiographic IVH clearance (r = 0.82, p = 0.02).

CONCLUSIONS

The pharmacokinetics of intraventricular TPA administration varies between individual patients. TPA dose does not need to exceed 2 mg. The optimal administration interval is every 8-12 h.

Intraventricular thrombolysis after endovascular treatment of a ruptured arteriovenous malformation

Intraventricular haemorrhage (IVH) secondary to arteriovenous malformation (AVM) rupture carries significant morbidity and mortality. External ventricular drainage of IVH is frequently complicated by thrombus formation within the ventricular catheter and therefore often unsuccessful at treating hydrocephalus in this setting. Intraventricular administration of recombinant tissue-type plasminogen activator (rtPA) has proved successful in the treatment of spontaneous panventricular haemorrhage. However, usage of rtPA is contraindicated in the setting of a ruptured AVM or aneurysm in which the bleeding source has not been secured. There are only a few reports of intraventricular thrombolysis in the treatment of IVH from AVM rupture. We present the case of successful application of rtPA to treat IVH after endovascularly securing the haemorrhage site of the AVM. Intraventricular thrombolysis remains an option for the treatment of IVH in the setting of AVM rupture and should be considered on a case-by-case basis.

Intraventricular thrombolysis after endovascular treatment of a ruptured arteriovenous malformation

Intraventricular haemorrhage (IVH) secondary to arteriovenous malformation (AVM) rupture carries significant morbidity and mortality. External ventricular drainage of IVH is frequently complicated by thrombus formation within the ventricular catheter and therefore often unsuccessful at treating hydrocephalus in this setting. Intraventricular administration of recombinant tissue-type plasminogen activator (rtPA) has proved successful in the treatment of spontaneous panventricular haemorrhage. However, usage of rtPA is contraindicated in the setting of a ruptured AVM or aneurysm in which the bleeding source has not been secured. There are only a few reports of intraventricular thrombolysis in the treatment of IVH from AVM rupture. We present the case of successful application of rtPA to treat IVH after endovascularly securing the haemorrhage site of the AVM. Intraventricular thrombolysis remains an option for the treatment of IVH in the setting of AVM rupture and should be considered on a case-by-case basis.

Management of intracranial aneurysms associated with arteriovenous malformations

Intracranial or brain arteriovenous malformations (BAVMs) are some of the most interesting and challenging lesions treated by the cerebrovascular neurosurgeon. It is generally believed that the combination of BAVMs and intracranial aneurysms (IAs) is associated with higher hemorrhage rates at presentation and higher rehemorrhage rates and thus with a more aggressive course and natural history. There is wide variation in the literature on the prevalence of BAVM-associated aneurysms (range 2.7%–58%), with 10%–20% being most often cited in the largest case series. The risk of intracranial hemorrhage in patients with unruptured BAVMs and coexisting IAs has been reported to be 7% annually, compared with 2%–4% annually for those with BAVM alone. Several different classification systems have been applied in an attempt to better understand the natural history of this combination of lesions and implications for treatment. Independent of the classification used, it is clear that a few subtypes of aneurysms have a direct hemodynamic correlation with the BAVM itself. This is exemplified by the fact that the presence of a distal flow-related or an intranidal aneurysm appears to be associated with an increased hemorrhage risk, when compared with an aneurysm located on a vessel with no direct supply to the BAVM nidus. Debate still exists regarding the etiology of the association between those two vascular lesions, the subsequent implications for patients’ risk of hemorrhagic stroke, and finally the determination of which patients warrant treatment and when. The ultimate goals of the treatment of a BAVM associated with an IA are to prevent hemorrhage, avoid stepwise neurological deterioration, and eliminate the mortality risk associated with recurrent hemorrhagic events. The treatment is only justifiable if the risks associated with an intervention are lower than or equivalent to the long-term risks of disability or mortality caused by the lesion itself. When faced with this difficult decision, a few questions need to be answered by the treating neu-rosurgeon: What is the mode of presentation? What is the symptomatic lesion? Which one of the lesions bled? What is the relationship between the BAVM and IA? Is it possible to safely treat both BAVM and IA? The objective of this review is to discuss the demographics, natural history, classification, and strategies for management of BAVMs associated with IAs.

Intraventricular tissue plasminogen activator for intraventricular hemorrhage caused by an arteriovenous malformation

The use of thrombolytics delivered through an external ventricular drain has improved outcomes in intraventricular hemorrhage, a disease with a poor prognosis; however, presence of an arteriovenous malformation is generally considered a contraindication to thrombolytic use. Due do the high mortality with the current standard of care, thrombolytics should be considered as an acceptable treatment option despite the presence of an arteriovenous malformation in certain clinical situations. We review the available literature and present an additional patient to make the case for the use of thrombolytics for intraventricular hemorrhage from an arteriovenous malformation.

Intraventricular tissue plasminogen activator for the prevention of vasospasm and hydrocephalus after aneurysmal subarachnoid hemorrhage

BACKGROUND

The sequelae of aneurysmal subarachnoid hemorrhage (SAH) include vasospasm and hydrocephalus.

OBJECTIVE

To assess whether intraventricular tissue plasminogen activator (tPA) results in less vasospasm, fewer angioplasties, or fewer cerebrospinal fluid shunting procedures.

METHODS

41 patients (tPA group, Hunt and Hess 3, 4, 5) from 2007 to 2008 received intraventricular tPA and lumbar drainage for a minimum of 5 days (range 5-7 days) and were compared to a matched group of 35 patients from 2006 to 2007 (Control, HH 3, 4, 5). Statistical comparison was done by t test analysis or Fisher exact tests and data are expressed as average+/-standard error of the mean.

RESULTS

There were no significant differences in demographic data, although the tPA group had a trend toward more surgical patients. The tPA group of patients had a significantly higher modified Fisher grade than controls (P<.001) and had a significantly better Hunt and Hess grade than controls (P<.03). The angioplasty rate was significantly lower among the tPA patients (15.0%+/-5.6) than controls (40.0%+/-8.5, P=.019). The number of days spent in severe vasospasm normalized over the 14-day monitoring period by transcranial Doppler was significantly lower in the tPA group (0.09+/-0.02) than controls (0.17+/-0.03). The shunt rate was significantly lower among tPA patients (17.5%+/-6.0) than controls (42.8%+/-8.6). There were 2 clinically silent tract hemorrhages in the tPA group (4.8%).

CONCLUSION

Intraventricular tPA is a safe and effective treatment for reducing both angioplasty and shunting rates in patients with SAH H&H Grades 3 to 5. A randomized trial is indicated.

A randomized, placebo-controlled pilot study of patients with spontaneous intraventricular haemorrhage treated with intraventricular thrombolysis

Intraventricular hemorrhage (IVH) occurring after spontaneous intracerebral hemorrhage (ICH) is an independent risk factor for mortality. The use of intraventricular urokinase (Uk) to reduce intraventricular blood clot volume and improve outcome was investigated. Patients with IVH requiring external ventricular drainage were recruited and randomized into a double-blind placebo controlled study. Assessments of collected cerebrospinal fluid (CSF) haemoglobin (Hb) and serial CT scans were performed. The study outcomes were: infection rates, length of stay in the intensive care unit, survival, National Institutes of Health Stroke Scale score; and modified Rankin Scale scores. Our results showed an increase in both the drained CSF Hb concentration in patients treated with Uk compared to placebo and in the rate of resolution clot volume. No differences were found in the other outcome measures but there was a trend towards lowered mortality in the group treated with Uk. Therefore, intraventricular Uk resulted in faster resolution of IVH with no adverse events.

Intraventricular fibrinolysis for intracerebral hemorrhage with severe ventricular involvement

Intraventricular hemorrhage (IVH) has been associated with poor prognosis in patients with spontaneous intracerebral hemorrhage. Several factors contribute to the deleterious effects of IVH, including direct mass effects of the ventricular blood clot on ependymal and subependymal brain structures, mechanical and inflammatory impairment of the Pacchioni granulations by blood and its breakdown products, and disturbance of physiological cerebrospinal fluid (CSF) circulation. Acute obstructive hydrocephalus represents a major life-threatening complication of IVH and is usually treated with an external ventricular drainage (EVD). However, treatment with EVD alone is frequently not sufficiently effective due to obstruction of the catheter by blood. In the past two decades, intraventricular fibrinolysis (IVF) has been increasingly used for maintenance of EVD functionality and acceleration of ventricular clot resolution in such patients. Unfortunately, there is no prospective, randomized controlled trial addressing the effect of IVF on clinical outcome. The available data on IVF consist of small retrospective case series, case reports, and a few prospective case-control studies, which are the subject of the present review article. All these studies, when considered in their entirety, suggest that IVF has a positive impact on mortality and functional outcome, and could be considered as a treatment option for selected patients.

Intraventricular thrombolysis with rt-PA in patients with intraventricular hemorrhage

OBJECTIVES

To evaluate safety, clinical feasibility, and outcome of intraventricular (IVen) administration of recombinant tissue plasminogen activator (rt-PA) in patients with intraventricular hemorrhage (IVH).

MATERIALS AND METHODS

Forty-eight patients with IVH who received IVen rt-PA were compared with 49 age-, sex-, Glasgow Coma Scale score-, and Intracerebral Hemorrhage score-matched control patients. Patients with IVH of aneurysmal or arteriovenous malformation origin were excluded. External ventricular drainage was inserted as soon as baseline CT was performed and rt-PA was administered within 12 ± 1 h after the ictal onset.

RESULTS

The outcome after 3 months was evaluated using the modified Rankin Scale (mRS). In addition, Glasgow Outcome Scale (GOS) and mortality were assessed. A good outcome, defined as mRS 0-3, was detected in 27% of patients from the control group vs 58% of patients in the IVen group; P = 0.003. GOS as other outcome scale yielded a significant difference between groups: 20% in the control group, vs 54% in the IVen group; P = 0.001. A statistically significant decrease in mortality was observed in the IVen group: 30% in the control vs 10% in IVen group; P = 0.003. No one patient died because of a complication which could be directly attributed to the IVen thrombolytic therapy.

CONCLUSIONS

IVen administration of rt-PA seems to be safe in cases of IVH. This pilot study shows that it may be associated with better outcomes. Further studies and clinical randomized trials are needed to establish indications and IVen administration protocols.

Intraventricular hemorrhage secondary to intranidal aneurysm rupture-successful management by arteriovenous malformation embolization followed by intraventricular tissue plasminogen activator: case report

BACKGROUND AND IMPORTANCE

Intraventricular hemorrhage related to arteriovenous malformation (AVM) rupture is associated with significant morbidity and mortality. Intraventricular tissue plasminogen activator (tPA) has been used to treat spontaneous intraventricular hemorrhage. We demonstrate the successful application of endovascular occlusion to seal the rupture site of an AVM followed by intraventricular tPA.

CLINICAL PRESENTATION

A 32-year-old woman presented with a right frontoparietal parasagittal AVM abutting the motor cortex. The AVM was diagnosed when the patient was 13 years old, and she initially underwent conservative management. At the age of 30, the patient suffered an intracranial hemorrhage, leaving her with left hemiparesis. After rehabilitation, the patient regained ambulation; however, she remained spastic and hyperreflexic on the left side. Two years after her major hemorrhage, she presented for elective treatment of her AVM. The patient was advised to undergo staged embolization before surgical resection of her AVM. The initial embolization was uneventful. A second embolization was complicated by intraventricular hemorrhage and coma. The patient was treated with placement of an external ventricular drain followed by embolization of intranidal aneurysm. After embolization of the intranidal aneurysm the ruptured, the patient was treated with intraventricular tPA. The patient had rapid clearance of the intraventricular hemorrhage and significant improvement in her neurological examination, following commands 24 hours later and returning almost to baseline.

CONCLUSION

This case demonstrates the feasibility of treating AVM-related intraventricular hemorrhage with tPA if the rupture source can be confidently sealed interventionally. This strategy can be lifesaving but needs further study to ensure its safety.

Massive intraventricular haemorrhage from aneurysmal rupture: patient proportions and eligibility for intraventricular fibrinolysis

Massive intraventricular haemorrhage (IVH) complicating aneurysmal subarachnoid haemorrhage (SAH) is associated with a poor prognosis. Small observational studies suggest favourable results from fibrinolysis of the intraventricular blood. We performed an observational study on IVH in a large series of patients with SAH to assess the proportion of patients that may benefit from fibrinolytic treatment. From our prospective database we retrieved patients with aneurysmal SAH admitted between January 2000 and January 2005. We calculated the proportion of patients with massive IVH and the proportion of patients that are eligible for fibrinolysis on basis of clinical and CT-scan characteristics and assessed neurological outcome in a treatment strategy without fibrinolysis. Poor neurological condition was defined as World Federation of Neurological Surgeons scale 4 and 5, poor outcome as death or dependence 3 months after SAH. Of the 573 patients admitted with aneurysmal SAH, 59 (10%; 95% confidence interval CI 8–13%) had massive IVH, of which 55 were in poor clinical condition. For these 55 patients, the case-fatality rate was 78% (95% CI 66–88%) and the proportion with poor outcome 91% (95% CI 81–97%). Of the 55 patients, 31 (56%, and 5% of all patients SAH within the study period) fulfilled our eligibility criteria and were considered suitable for intraventricular fibrinolysis. At 3 months, 30 of these 31 eligible patients (97%; 95% CI 85–100%) had a poor outcome. Massive IVH occurs in 10% of patients with aneurysmal SAH. Half of these patients may benefit from intraventricular fibrinolysis. Without fibrinolysis outcome is almost invariably poor in these patients.

Intraventricular thrombolysis for massive intraventricular hemorrhage due to periventricular arteriovenous malformations: no absolute contraindications as rescue therapy prior to surgical repair or embolization?

Intraventricular hemorrhage (IVH) after bleeding from a cerebral aneurysm or an arteriovenous malformation (AVM) results in a high mortality. A limited number of publications have shown that intraventricular thrombolysis with e.g. recombinant tissue plasminogen activator (rt-PA) can be a therapeutic option in IVH. However, this treatment is considered as an absolute contraindication prior to the treatment of the bleeding source. We report the successful use of low-dose intraventricular thrombolysis (rt-PA) in two cases of life-threatening intraventricular hemorrhage due to periventricular AVMs as rescue therapy, even prior to source control of the bleeding. Our observations, together with nine comparable published cases, illustrate that this treatment might be useful to clear the intraventricular blood and lower intracranial pressure. It might also improve neurological outcome and mortality in these selected patients. This suggests that hemorrhage from a periventricular AVM, even before surgical resection or endovascular embolization, is not necessarily an absolute contraindication for intraventricular thrombolysis in patients with massive IVH.

Current Updates in Perioperative Management of Intracerebral Hemorrhage

Spontaneous ICH remains a formidable disease that continues to disable and kill the majority of its victims. Treatment of the disease continues to be controversial and without any proved success, such as improvement in the disease mortality or the resulting disability in survivors. Primary prevention is the most effective medical intervention. Nevertheless, as the population continues to age and patients remain undertreated for hypertension, the incidence of ICH likely will increase, resulting in significant socioeconomic impact on society in the coming years. It is imperative that more research be conducted to improve treatment and outcomes of patients who have ICH. Unlike ischemic stokes or other causes of hemorrhagic stroke, such as SAH, where major advancement of treatment has led to improved outcomes, the increased incidence of ICH has not been matched with any considerable improvement in treatment. This burden to improve therapeutic interventions for patients who have ICH should be shared by all neurosurgeons, stroke neurologists, and critical care physicians who care for these patients on a regular basis. It is hoped that early diagnosis and resuscitation, prevention of hematoma growth, selective surgery or minimally invasive clot evacuation, and judicious critical care and rehabilitation will combine to lessen the burden of this disease.

Treatment of intraventricular hemorrhage with intraventricular administration of recombinant tissue plasminogen activator A clinical study of 18 cases

OBJECTIVE

Intraventricular hemorrhage is associated with a very poor outcome. Simple external ventricular drainage alone has not resulted in a decline of mortality. The aim was to study the effect of direct intraventricular administration of recombinant tissue plasminogen activator (rtPA).

PATIENTS AND METHODS

A retrospective series of eighteen adult patients with severe intraventricular hemorrhage, admitted to our university hospital, was studied for the effect of direct intraventricular administration of recombinant tissue plasminogen activator (rtPA). rtPA was administered in a dosage of 2mg. The injection was repeated at 12h intervals until serial CT scans showed a substantial reduction of intraventricular blood.

RESULTS

The total of rtPA doses per patient ranged from 2 to 32mg. Seven out of 18 patients showed good neurological recovery, 4 died. Only one patient had a complication which could be directly attributed to the intraventricular thrombolytic therapy.

CONCLUSION

We conclude that the procedure of intraventricular administration of a thrombolytic agent, i.e. rtPA, seems effective in lysis of the intraventricular hematoma and may, therefore, improve outcome.

Ruptured saccular aneurysm of distal vertebral artery fenestration managed with Guglielmi detachable coils and intraventricular tissue plasminogen activator

BACKGROUND

Aneurysms associated with vertebrobasilar fenestrations are uncommon. We report on an unusual presentation of such aneurysm with a dedicated arterial pedicle, manifesting with significant intraventricular hemorrhage. Equally important, the aneurysm was managed in a multidisciplinary fashion, which, we think, greatly contributed to a good outcome.

CASE DESCRIPTION

A 55-year-old man presented in good condition after subarachnoid and massive intraventricular hemorrhage. The aneurysm location and the extent of intraventricular hemorrhage both presented concerns regarding treatment approach. The aneurysm was first treated with transarterial coil obliteration, and intraventricular tissue plasminogen activator (tPA) infusion was given, with rapid resolution of evolving hydrocephalus. The patient had an excellent outcome.

CONCLUSION

To our knowledge, this is the first report of a vertebrobasilar fenestration saccular aneurysm with a dedicated pedicle projecting toward the foramen of Magendie with significant intraventricular hemorrhage. In addition, this patient was successfully managed with endovascular obliteration and intraventricular tPA infusion.

Intraventricular Hemorrhage after Aneurysmal Subarachnoid Hemorrhage: Pilot Study of Treatment with Intraventricular Tissue Plasminogen Activator

OBJECTIVE

Intraventricular (IVen) hemorrhage is considered a predictor of poor outcome after subarachnoid hemorrhage (SAH). This prospective study examines the feasibility and outcome of administration of IVen tissue plasminogen activator (tPA) after aneurysmal SAH.

METHODS

Ten patients with SAH who received IVen tPA after the aneurysm had been secured were compared with 10 age-, sex-, and Glasgow Coma Scale score-matched control patients. The primary end point was third and fourth ventricle clot resolution. IVen blood was quantified by use of the Graeb and Le Roux scales on admission and at an additional time (equal or longer for the control group) after the injection was terminated.

RESULTS

Six men and four women with a mean age of 52 years in each group were evaluated. On average, 3.5 mg tPA was injected 68 +/- 51 hours after admission without ensuing complications. Although the treated group had significantly more IVen blood on admission than control subjects (mean Le Roux scale +/- standard deviation, 11 +/- 3 versus 7.6 +/- 4.2, P = 0.055, and mean Graeb scale +/- standard deviation, 8.5 +/- 2.3 in tPA versus 5.3 +/- 3, P < 0.02), it also had a significant decrease in the amount of IVen blood (mean Le Roux and Graeb scale decrease +/- standard deviation, 6.7 +/- 3.3 and 4.8 +/- 2 in tPA patients versus 0.9 +/- 3.2 and 0.5 +/- 2.6 in control subjects, P = 0.002). The tPA group had a non-statistically significantly shorter length of stay, decreased mortality, and better Glasgow Outcome Scale and modified Rankin Scale scores at discharge. Treated survivors showed a decreased need for shunt placement (2 [22%] of 9 patients versus 5 [83%] of 6 control subjects, P = 0.04).

CONCLUSION

This pilot study shows that IVen tPA administration is feasible without complications after SAH and may be associated with better outcomes. These results warrant a randomized clinical trial.

Tissue plasminogen activator levels after single intracisternal injection in patients with subarachnoid hemorrhage

Tissue plasminogen activator (tPA) levels were investigated in the cisternal fluid of patients with subarachnoid hemorrhage treated with single intracisternal injection of recombinant tPA during radical surgery for ruptured aneurysms. Seven patients received different doses of tPA: two of 400 microg/ml, three of 500 microg/ml, one of 700 microg/ml, and one of 800 microg/ml in a total amount of 20 ml distilled water at pH 7. Cerebrospinal fluid samples were taken directly from the cisternal fluid at 15-minute incubation after injection, immediately after irrigation during surgery, and by lumbar tap 2 days after surgery. Cisternal tPA levels decreased to about 60% of the mean injected doses after 15-minute incubation. Simple linear regression analysis showed these tPA levels after incubation correlated with the initial doses. After copious irrigation with Ringer solution at pH 8, tPA levels decreased rapidly without correlation with the initial doses. After spinal drainage for 2 days, tPA levels further decreased by an order of 10(-4) to 10(-6) from the initial dose. These values were still greater than normal controls. The final values of tPA levels were not related to the initial dose. None of the patients suffered from systemic or wound complications. Cisternal tPA injection with increased doses and irrigation may be beneficial for the selective rapid removal of blood clots with controllable safety.

Intraventricular Thrombolysis Speeds Blood Clot Resolution: Results of a Pilot, Prospective, Randomized, Double-blind, Controlled Trial

OBJECTIVE

Animal models and clinical studies suggest that intraventricular thrombolysis improves clot resolution and clinical outcomes among patients with intraventricular hemorrhage. However, this intervention may increase the rates of rebleeding and infection. To assess the safety and efficacy of intraventricular thrombolysis, we conducted a pilot, randomized, double-blind, controlled, multicenter study.

METHODS

Patients with intraventricular hemorrhage requiring ventriculostomy were randomized to receive intraventricular injections of normal saline solution or urokinase (25,000 international units) at 12-hour intervals. Injections continued until ventricular drainage was discontinued according to prespecified clinical criteria. Head computed tomographic scans were obtained daily, for quantitative determinations of intraventricular hemorrhage volumes. The rate of clot resolution was estimated for each group.

RESULTS

Twelve subjects were enrolled (urokinase, seven patients; placebo, five patients). Commercial withdrawal of urokinase precluded additional enrollment. The urokinase and placebo groups were similar with respect to age (49.6 versus 55.2 yr, P = 0.43) and presenting Glasgow Coma Scale scores (7.14 versus 8.00, P = 0.72). Randomization to the urokinase treatment arm (P = 0.02) and female sex (P = 0.008) favorably affected the clot resolution rate. The sex-adjusted clot half-life for the urokinase-treated group was reduced 44.6%, compared with the value for the placebo group (4.69 versus 8.48 d).

CONCLUSION

Intraventricular thrombolysis with urokinase speeds the resolution of intraventricular blood clots, compared with treatment with ventricular drainage alone.

Current management of intraventricular hemorrhage

BACKGROUND

Intraventricular hemorrhage (IVH) continues to present a challenge to neurosurgeons, often being accompanied by significant morbidity and mortality. The purpose of this paper is to present a review of the recent literature concerning the treatment of patients with IVH, and describe our current management scheme for this disorder.

METHODS

A literature search was conducted to identify key articles pertaining to the pathophysiology and treatment of IVH, focusing on the more recent articles. The bibliographies of selected papers were also screened for additional useful publications.

RESULTS

Management of IVH is primarily directed at controlling intracranial pressure through an external ventricular drain (EVD), but this catheter often becomes occluded by coagulated blood. The fibrinolytic system of the cerebrospinal fluid is limited, and blood may remain in the ventricles for months after a hemorrhage. IVH has a poor prognosis, partly because of the continuing mass effect of blood clots on the ventricular walls. Therefore, investigators have administered fibrinolytic agents directly into the ventricles of patients with IVH. Clinical studies of fibrinolytic therapy for IVH have found a 30 to 35% reduction in mortality with treatment, but have not yet clearly documented an improved neurologic outcome for the survivors.

CONCLUSIONS

Fibrinolytic therapy may be life saving in severe cases of IVH. While many issues need to be resolved, our current practice is to administer intraventricular tissue plasminogen activator (t-PA or alteplase) if hemorrhage involves > or =30% of the volume of one of the lateral ventricles and/or the 3(rd) or 4(th) ventricle. We currently give t-PA after ruling out or treating a possible source of further bleeding, such as an unsecured aneurysm.

Recombinant tissue plasminogen activator in the treatment of intraventricular hemorrhage secondary to periventricular arteriovenous malformation before surgery: case report

OBJECTIVE AND IMPORTANCE

Intraventricular hemorrhage (IVH) is known to cause acute obstructive hydrocephalus, refractory elevated intracranial pressures (ICPs), and lowered cerebral perfusion pressures, leading to cortical ischemia. Frequent obstruction of external ventricular drains as a result of thrombus is a recurring theme. We present a case of IVH secondary to periventricular arteriovenous malformation (AVM) that was not visible at admission angiography and was treated by intraventricular infusion of recombinant tissue plasminogen activator before surgical intervention.

CLINICAL PRESENTATION

An 11-year-old boy presented with acute onset of headache followed by two seizures, loss of consciousness, decerebration, right temporal hematoma, IVH, and acute obstructive hydrocephalus.

INTERVENTION

A right external ventricular drain was placed but functioned poorly. ICP could not be controlled by conventional methods. Five milligrams of recombinant tissue plasminogen activator was injected into the ventricular system via the external ventricular drain. This was repeated daily for 4 days. This treatment resulted in progressive improvement in ICP and clinical status. Once the clot partially cleared, magnetic resonance imaging and magnetic resonance angiography suggested the presence of a right periventricular arteriovenous malformation, which was confirmed by angiography and subsequently resected.

CONCLUSION

Recombinant tissue plasminogen activator is effective in resolving IVH causing obstructive hydrocephalus and uncontrollable ICP posing a life-threatening situation, secondary to ruptured arteriovenous malformation, before surgical intervention.

Fibrinolytic therapy in intraventricular hemorrhage

OBJECTIVE

To review the literature concerning intraventricular administration of fibrinolytic agents to treat patients with intraventricular hemorrhage (IVH).

DATA SOURCES

An extensive literature search (MEDLINE, EMBASE, Conference Proceedings) was conducted to identify articles in English published between 1966 and May 2000 pertaining to the pathophysiology of IVH and its treatment by intraventricular administration of recombinant tissue plasminogen activator (alteplase) or urokinase (u-PA). The bibliographies of selected identified articles were also screened for publications not found in the computerized search.

STUDY SELECTION

All pertinent publications were reviewed and considered. Those describing the intraventricular administration of fibrinolytic agents to patients with IVH were included.

DATA SYNTHESIS

IVH has a poor prognosis, partly due to the mass effect of blood clots on the ventricular walls. The cerebrospinal fluid has a limited fibrinolytic system. Therefore, clots may remain in the ventricles for months after a hemorrhage. The management of IVH is primarily directed at controlling intracranial pressure through an external ventricular drain, but this catheter often becomes occluded by coagulated blood. To overcome this problem, and to dissolve the residual blood clot, investigators have administered alteplase or u-PA directly into the ventricles of patients with IVH. Complications of this therapy include infection and possible rebleeding. Clinical studies of fibrinolytic therapy for IVH have found a 30-35% reduction in mortality with treatment, but to date, have not clearly documented improved neurologic outcome of the survivors.

CONCLUSIONS

Fibrinolytic therapy with alteplase or u-PA may be life-saving in severe cases of IVH. Yet many technical issues remain to be resolved, such as the optimal dose, frequency, method, timing, and duration of administration of the agent. Additional randomized, double-blind, placebo-controlled studies need to be performed so that the true value of this therapy can be assessed.